Beyond the obvious: pneumothorax masquerading as a cardiac emergency

A non-smoking housewife in her 70s with underlying hypertension, dyslipidaemia and kyphoscoliosis presented with chest pain and acute respiratory distress. Reduced breath sounds were noted over the right lung. Initial ECG showed ST-segment elevation in leads V3-V5, and focused echocardiography showed septal wall hypokinesia, suggestive of myocardial infarction. Fibrinolysis therapy was started due to percutaneous coronary intervention service limitation. Despite treatment, there were no signs of improvement. A right-sided pneumothorax was detected on CXR done near the end of fibrinolysis. Consequently, a right chest drain was performed. Patient's symptoms, ST elevation and hypokinetic left ventricle wall resolved afterwards. A talc pleurodesis was done prior to discharge with no evidence of pneumothorax recurrence on follow-up. This case highlights the atypical presentation of pneumothorax, emphasising the importance of comprehensive clinical assessment, including lung point-of-care ultrasound, in emergency settings to expedite diagnosis, prevent inappropriate treatment and improve patient outcomes.